Nurses' clinical leadership in the hospital setting: A systematic review

Abstract Aim This study aims to identify the most effective interventions to facilitate nurses' clinical leadership in the hospital setting. Background There is a gap in the literature on the identification and measurement of effective interventions for leadership skill development among clinical nurses in hospitals. To the best of our knowledge, no systematic review has been performed on this issue. Evaluation A systematic review was conducted. The PubMed, CINAHL, PsycINFO and Cochrane databases were reviewed. Data extraction, quality appraisal and narrative synthesis were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Key issues The evidence reveals that interventions designed to promote nurses' clinical leadership are complex, requiring that cognitive, interpersonal and intrinsic competencies as well as psychological empowerment, emotional intelligence and critical reflexivity skills be addressed. Conclusions The development of multicomponent, theory‐based and mixed‐format programmes may be more suitable to facilitate nurses' clinical leadership in the hospital setting. Implications for Nursing Management Strategies to facilitate nurses' clinical leadership in the hospital setting should address simultaneously the knowledge and ability of bedsides nurses to solve the practical problem collaboratively with a sense of control, competency and autonomy. Hence, it would promote high quality care, satisfaction and retention of bedside nurses.


| BACKGROUND
Clinical leadership is an ambiguous and context-dependent concept (Larsson & Sahlsten, 2016). A growing body of literature has recently attempted to clarify this relatively new concept (Chávez & Yoder, 2015;Mianda & Voce, 2017;Stanley & Stanley, 2018). However, its meaning is still unclear, especially in the hospital context. For this review, nurses' clinical leadership refers to nurses who are directly involved in providing nursing care at the bedside and who exert influence on health care team colleagues to achieve positive patient outcomes, even though no formal authority has been vested in them (Chávez & Yoder, 2015;Patrick et al., 2011).
Nurse clinical leaders can be found across the spectrum of health organisations (Stanley & Stanley, 2018). In hospitals, where care is becoming more complex, with more demanding and high acuity patients, shorter lengths of stay and staffing shortages, nurses play a key leadership role (Daly et al., 2014). Nurses at the bedside are accountable for and oversee the completion of patient care as well as directly lead and manage the provision of safe patient care (Larsson & Sahlsten, 2016). They identify areas for improvement in advocating for patients and their families, motivate other members of the care team to act on patient care and lead change initiatives to solve problems that arise in daily clinical practice (Daly et al., 2014;Doherty, 2014). In addition, they identify inefficiencies in organisational structures, workflows, policies and procedures that affect the delivery of optimal patient care (Casey et al., 2011;Doherty, 2014;Patrick et al., 2011).
Promoting clinical leadership among frontline nurses is critical given their potential impact on patient outcomes and experiences (Aiken et al., 2011), team performance outcomes (O'Donovan et al., 2021), nurses' job satisfaction and retention (Chappell & Richards, 2015), quality, safety and effectiveness of care (Casey et al., 2011;Patrick et al., 2011).
According to the collaborative report between the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation, the future of nursing depends on educating and supporting all levels of nurse leaders (IOM, 2011). For example, the International Council of Nursing (ICN), launched in 1995, the ICN LFC programme aims to prepare nurses with the leadership skills required to implement organisational change to improve nursing practice and achieve better health outcomes (Ferguson et al., 2016). Likewise, magnet hospitals, organisations that receive special designations for having created excellent nursing practice environments and providing excellent patient care, make significant investments in the clinical leadership development of their nursing staff (McCaughey et al., 2020). Despite these and other initiatives, several authors point out that nurses are not prepared to exercise leadership in hospital settings and call for effective strategies to prepare them for clinical leadership skills at the bedside (Curtis et al., 2011;Daly et al., 2014;Larsson & Sahlsten, 2016).
There is a gap in the literature on the identification and measurement of effective interventions for leadership skill development among clinical nurses in the hospital setting. To the best of our knowledge, no systematic review has been performed on this issue. Mianda and Voce (2018), in a recent systematic literature review, focused on interventions for clinical leadership among frontline health care providers without discriminating the context or participants, such as doctors and managers.
Nurses' leadership skills are acknowledged as playing an important role in the hospital setting and the health outcomes of patients (Daly et al., 2014). Thus, this systematic literature review will benefit the health sector and service consumers by identifying and evaluating evidence on effective interventions for the development of nurses' leadership skills. This knowledge will enable better utilization of resources and enhance programme development through the identification of the most effective interventions for leadership skill development for clinical nurses. Therefore, the objective of this systematic review was to identify the most effective interventions to facilitate nurses' clinical leadership in the hospital setting.

| Design
A systematic review of the most recent literature was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009) for reporting.

| Search methods
A systematic review of studies published in the PubMed, CINAHL, PsycINFO and Cochrane databases was performed in May 2021. For these electronic searches, as illustrated in Table 1, the terms 'intervention', 'clinical leadership', 'nursing' and their synonyms were combined with the Boolean operators 'AND' and 'OR'. To improve search sensitivity and avoid omitting relevant studies, MeSH terms and the keywords identified in the selected studies were used. In particular, given the ambiguity of the term 'clinical leadership' and its recent use, different free terms used under the same umbrella and with the same meaning were included. The following limits were set: language, English and Spanish and year of publication within the last 10 years to ensure that the search was current.
To complete the electronic searches, the 'snowballing' technique was applied by reviewing the reference lists of all selected studies and identifying possible additional papers. Manual reviews of the journals relevant to the area of interest were carried out: 'Journal of Nursing Management' and 'Journal of Nursing Administration'.
Studies were selected based on the application of the inclusion and exclusion criteria presented in Table 2.

| Quality appraisal
The selected studies were independently evaluated by two authors (CGL and MVC) according to the methodological quality criteria described by PRISMA for systematic reviews, which includes 27 criteria (Urrútia & Bonfill, 2010), and by TREND for quasiexperimental studies, which includes 22 criteria (Vallvé et al., 2005).
The latter criteria were scored as 'yes', 'no', 'unclear', or 'not applicable'. A total score was calculated by summing the 'yes' items, giving each study a score between zero and the total number of items evaluated in each checklist (i.e., 17, 18 or 19). Studies with a score equal to or lower than half of the items evaluated were considered to have a high level of bias and, therefore, poor methodological quality. Studies with a medium or high quality had higher scores. Disagreements between the two reviewers were resolved through discussion. No studies were excluded after evaluation. Due to the type of study identified, the risk of bias could not be assessed (Higgins et al., 2011).

| Synthesis
The data were analysed considering the research objectives, design and sample; the characteristics of the intervention; the instruments used to evaluate the intervention; and the main results of the studies reviewed. We synthesized the results through the formulation of interventions, the strategies used in interventions and the effectiveness of interventions in facilitating clinical leadership. This analysis process was first performed by the two researchers separately (CGL and MVC), and they then jointly compared, clarified and reached a consensus on the findings.

| Search outcomes
In the initial search, 2242 studies were identified. After removing duplicates (n = 102), the abstracts of 1140 articles were examined for their potential inclusion in the systematic literature review, of which 1051 were considered irrelevant for the purpose of this review. The remaining 89 articles were evaluated by two reviewers (CGL and MVC) independently and in full text, after which 83 articles were excluded for not meeting the inclusion criteria. Furthermore, no relevant article was found using the 'snowball' technique. Ultimately, six studies were included in this review (see Figure 1). Table 3 presents the main characteristics of the studies selected for this review. Of the six included articles, one was a systematic review, which included 17 pre-post studies, and the others were quasiexperimental studies. Leggat et al. (2016) conducted their study in Australia, and the remaining five were carried out in the United States (Abraham, 2011;Chappell & Richards, 2015;Fitzpatrick et al., 2016;MacPhee et al., 2014;Shen et al., 2018). Table 3 details the methodological quality of the studies. In general, the studies presented medium quality (n = 4) and a lesser extent, high quality (n = 2). The most commonly found deficiencies, based on the criteria analysed for each type of study design, were related to the T A B L E 2 Selection criteria for the studies GUIBERT-LACASA AND V AZQUEZ-CALATAYUD lack of theories used in designing behavioural interventions; insufficient description of the locations where data were collected; and lack of follow-up, description and analysis of differences between groups in the follow-up, among other factors.

| Main findings of the studies
The analysis of the studies reviewed reveals various interventions aimed at promoting nurses' clinical leadership in the hospital context.
For ease of understanding, the main findings are presented in three sections relating to the competencies addressed by the interventions, the mechanisms used and their evaluation.

| Competencies of interventions to promote clinical leadership
Interventions to promote clinical leadership addressed three core competencies: (1) cognitive, (2) interpersonal and (3) intrinsic. Each of these is detailed below. The competencies of the interventions designed to promote nurses' clinical leadership are reflected in Table 3.
These competencies enable the development and application of knowledge for practical problem solving, making good decisions and controlling learning and behaviour (Abraham, 2011;Fitzpatrick et al., 2016;Leggat et al., 2016;MacPhee et al., 2014;Shen et al., 2018). More specifically, studies combine didactic and interactive learning through online and/or face-to-face training sessions (Leggat et al., 2016), discussion groups and role-play activities to promote the translation of acquired leadership knowledge into practice (Chappell & Richards, 2015;Leggat et al., 2016;MacPhee et al., 2014;Shen et al., 2018).
Programmes that address these types of competencies improve nurses' decision-making skills in daily practice, their ability to lead change within inpatient services (Fitzpatrick et al., 2016;Shen et al., 2018)

| Interpersonal competencies
Other competencies identified as essential are interpersonal competencies, which refer to individual capacities and social skills with which to establish stable and effective relationships with other individuals, patients, families and professionals (Abraham, 2011;Fitzpatrick et al., 2016;Leggat et al., 2016;MacPhee et al., 2014;Shen et al., 2018). Strategies used to develop these competencies include mentoring and team reinforcement systems.

| Mechanisms to promote clinical leadership
The main mechanisms shaping interventions to promote clinical leadership are described below in terms of programme development frameworks, delivery formats, programme durations and types, recipients and organisational support.

| The recipients of the intervention and context of application
Most of the studies included focused interventions on care nurses (Abraham, 2011;Chappell & Richards, 2015;Fitzpatrick et al., 2016;MacPhee et al., 2014;Shen et al., 2018), while only one study included other health professionals (Leggat et al., 2016).
The profiles of the care nurses surveyed also varied in terms of years of professional experience, ranging from recent graduates (Chappell & Richards, 2015) to those with 1 year (Fitzpatrick et al., 2016) and those with at least 5 years of professional experience (Abraham, 2011). Shen et al. (2018) and Leggat et al. (2016), while not specifying the years of experience of the studied nurses, noted that they had to have a high degree of expertise in the particular area of work.
Although all interventions have been carried out in hospital settings, two specify that they have been carried out in the acute and/or long-term context without describing the study setting in more detail (Leggat et al., 2016;Shen et al., 2018). Therefore, one of the proposed initiatives is to release time for project work and online knowledge networks to facilitate connections among professionals. Another type of support alluded to by Abraham (2011) would be structural support by the creation of committees, workgroups or councils to facilitate the active participation of these nurses.

| Effectiveness of clinical leadership interventions
To assess the effectiveness of these interventions at promoting the clinical leadership of nurses, it is necessary to have valid and reliable measurement instruments. For the purposes of this paper, any type of questionnaire, scale, test or functional test used to assess the interventions described above is considered an instrument.
Numerous instruments have been identified in the literature reviewed, whose contexts of application, reliability and dimensions identified for their operationalization are described in Table 4. Most of them were generic, either because of the context in which they are developed, inpatient or outpatient settings, or because of the discipline of application. The instruments used were validated and demonstrated excellent reliability, as shown in Table 4. However, none assessed all the competencies and skills that have been considered key in a clinical leadership intervention. It should be noted that in addition to these instruments, no studies included patient outcome measures that reflect whether the interventions to foster nurses' clinical leadership were effective at the level of safety and quality.
In this regard, and given the heterogeneity of competencies, mechanisms and instruments used to assess the results, it is not possible to determine which intervention is more effective in facilitating clinical leadership. Despite this, it should be mentioned that in all the studies, significant improvements were obtained after implementing the intervention in terms of knowledge, skills and leader empowerment behaviours (Abraham, 2011;Chappell & Richards, 2015;Fitzpatrick et al., 2016;Leggat et al., 2016;MacPhee et al., 2014;Shen et al., 2018). With regard to the knowledge and skills, improvements were obtained in decision making, negotiation and communication skills (Shen et al., 2018). For instance, they described an increased leadership involvement of the participants in their unit and departmental committees, workgroups and councils. Other empowerment behaviours were publishing an article, beginning a research study and leading practice initiatives as staff nurses to improve the quality and safety of patient care (Abraham, 2011). The need to include cognitive, interpersonal and intrinsic competencies in these interventions is a finding consistent with a previous integrative review in which a nurse's clinical leader is described as demonstrating three attributes: clinical competence and expertise, skills for building teams and relationships and personal qualities (Mannix et al., 2013). This result, however, could not be compared with those obtained in a recent systematic review (Mianda & Voce, 2018) focused on interventions for clinical leadership among frontline health care providers because the specific competencies to be developed are not identified. Moreover, as previously mentioned, Mianda and Voce (2018) describe the results without discriminating against the context, inpatient from outpatient settings, or participants such as doctors and managers. Given that clinical leadership remains an ambiguous and unclear concept (Chávez & Yoder, 2015;Mianda & Voce, 2017;Stanley & Stanley, 2018), knowledge of core competencies will provide a common understanding to guide the further development of effective interventions and tools to measure the clinical leadership of nurses in the hospital setting (Larsson & Sahlsten, 2016).

| DISCUSSION
Nevertheless, as the leadership role is influenced by context (Larsson & Sahlsten, 2016), further research is essential to identify characteristic distinctions in disparate settings.
In this sense, an interesting result of this review is that although The results of the present review broaden this notion because they not only identify the competencies necessary to develop but also suggest different strategies to be used to develop each of the three core competencies: didactic and interactive learning strategies to develop cognitive competencies, mentoring and team reinforcement to acquire interpersonal competencies and experiential learning to develop intrinsic competencies (Abraham, 2011;Chappell & Richards, 2015;Fitzpatrick et al., 2016;Leggat et al., 2016;MacPhee et al., 2014;Shen et al., 2018). In this sense, integrating methodologies such as simulations, role playing and case studies (Vázquez-Calatayud et al., 2017) into training may be interesting, which may allow nurse to improve their clinical leadership competencies and, for instance, to empower them to participate in the design and development of improvements that emerge bottom-up.
Some controversy has been found in terms of the experience advised for preparation as leaders. Some authors advise preparing nurses with some degree of experience and expertise in the given service (Leggat et al., 2016;Shen et al., 2018). This finding coincides with the assumptions that defend the theory developed by Patricia Benner (1982) (Chappell & Richards, 2015). In this regard, it is necessary to point out that for nurses to develop their full potential as clinical leaders, their preparation is fundamental. Rarely are nurses trained in the intrinsic competencies that are key to dealing with the many situations they face in daily practice. A clear example is the global pandemic that nursing students and professionals have had to cope with (Mohebbi & Eslami, 2021;Vázquez-Calatayud, Rumeu-Casares, et al., 2021).
It is worth mentioning that in all studies reviewed, significant improvements were achieved after implementing the intervention in terms of knowledge, skills and behaviours in leadership and/or psychological and emotional empowerment (Abraham, 2011;Chappell & Richards, 2015;Fitzpatrick et al., 2016;Leggat et al., 2016;MacPhee et al., 2014;Shen et al., 2018). The improvement in knowledge and leadership skills reported by all studies, and in line with Larsson and Sahlsten (2016), is considered key to gaining the trust of others and positively impacting quality and patient safety. As bedside nurses occupy an informal leadership position, the trust placed in them is essential. Nurses gain confidence in bedside nurses as leaders when they demonstrate their knowledge of practical problem solving, good decision making, learning and behaviour management (Fitzpatrick et al., 2016;Leggat et al., 2016;MacPhee et al., 2014;Shen et al., 2018), enabling them to achieve a certain status or authority as leaders (Larsson & Sahlsten, 2016).
The improvement of psychological and emotional empowerment is considered another outcome of great interest. According to the recent study by Khoshmehr et al. (2020), better psychological empowerment may lead to reduced mental pressures and work environment stressors and enhance decision-making power and moral behaviour performance by nursing staff, ultimately resulting in the creation of moral courage in nurses. In these circumstances, nurses can properly manage complex situations in daily practice, which is more common in the hospital setting. By having a sense of control, competency and autonomy, they feel more motivated and satisfied, which has a positive impact on retention and the quality of care provided (Khoshmehr et al., 2020;Marufu et al., 2021). This has been particularly crucial during the coronavirus outbreak to improve job performance (Mohebbi & Eslami, 2021 (Vallvé et al., 2005), implying that the randomized controlled studies were limited. Therefore, future studies should adopt designs that provide more rigorous evidence. Moreover, the use of self-administered questionnaires for data collection in all studies may have led to social desirability bias, with participants providing scores that they felt were more acceptable to the researchers. Future studies could also use the triangulation method to thoroughly examine the effectiveness of leadership programmes in order to understand more clearly the dynamics of the leading process through qualitative and quantitative evalua-

| IMPLICATIONS FOR NURSING MANAGEMENT
The knowledge provided by this review will help enlighten nurse managers and lectures to design educational and management strategies directed at developing competent clinical nurse leaders in the hospital setting and subsequently at enhancing the quality of care, satisfaction and retention of bedside nurses. In particular, theory-based, mixedformat and multicomponent programmes should address simultaneously the knowledge and ability of bedsides nurses to solve the practical problem collaboratively with a sense of control, competency and autonomy. Hence, these programmes may, for example, help nurses to actively participate in committees and working groups, propose projects to improve daily practice in the units or have a voice in multidisciplinary team rounds.
This review will also serve as a starting point to define the focus of future interventions. Determining the effectiveness of nurses' clinical leadership for patients through intervention-type studies that include clinical outcome indicators could demonstrate the importance of investing in clinical leaders at the bedside in health care organisations.

ACKNOWLEDGEMENT
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

CONFLICT OF INTEREST
No conflicts of interest have been declared by the authors.

AUTHOR CONTRIBUTIONS
CGL and MVC made substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; are involved in drafting the manuscript or revising it critically for important intellectual content; and given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. CGL and MVC agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any of the work are appropriately investigated and resolved.

DATA AVAILABILITY STATEMENT
Authors do not wish to share the data.